Health and financial incentive - Essay Example

The health of an individual or a population is influenced less by medical care than by broad socioeconomic factors. In 1986, people in the United States with a yearly income of less than $9000 had a death rate three to six times higher than those with a yearly income of $25,000 or more. The mortality rate for heart disease among laborers is more than twice the rate for managers and professionals. The incidence of cancer increases as family income decreases, and survival rates are lower for low-income cancer patients. Higher infant mortality rates are linked to low income and low educational level. Not only does the income level of individuals affect their health and life expectancy, the way in which income is distributed within communities also appears to influence the overall health of the population. In the United States, overall mortality rates are higher in states that have a more unequal distribution of income, with greater concentration of wealth in upper income groups. Some social scientists have concluded that the toxic health effects of social inequality in developed nations result from the psychosocial stresses of social hierarchies and social oppression, not simply from material deprivation. It may be that health care needs do not correspond totally to the desires of individuals with regard to their health – partly because of some needs being identified by someone other than the patient and partly because some things that we need might not necessarily be wanted and vice versa. In addition, desires and needs are not independent of the level of supply available, and may be based upon knowledge and awareness of the existence of certain facilities. Such facilities and services have often been provided for elderly people and others requiring care provision by agents on the basis of factors other than their needs or wants. The proportion of an individual’s needs that are actually met by care services is subject to debate, but even if the proportion were approaching 100% for one person, this is unlikely to be regarded as equitable or fair, if for other people the proportion was much lower. In such a situation inequities and inequalities are possibly being compounded rather than reduced. In addition, should those whose own actions create a need for care services (e.g. heavy smokers or drug abusers) be treated differently from those who have similar needs through no ‘fault’ of their own? The notions of ‘comparative need’ and ‘relative need’ thus have to be brought into consideration, and this is where the professionals have an important role to play, subject to the proviso mentioned above, that they should be prepared to make explicit their own values and ideas of justice and equity and recognize that other views are also important. In addition, it is highly likely that many of the demands placed on health care services by consumers are also unnecessary, based not on specific health care needs but on other life problems, or arising out of health-damaging behavior, which people believe that the health care system can fix. It has been reported that more than 50% of the population of England is currently overweight or obese, and it is known that obesity reduces life expectancy by 9 years on average. There was a 25% increase in the number of overweight or obese children between 1995 and 2002 .In contrast, just 40% of men and 26% of women take enough exercise – defined as 30 min of moderately intense physical activity on five or more occasions per week. (Welness). Furthermore, the ever-increasing incidence and prevalence of substance abuse and self-harm add to the pressures confronting the health service. In addition, there are people who feel ill and present to the health care system, but in whom there is no underlying pathology or disease. This phenomenon has been attributed to medically unexplained physical symptoms (MUPS) or hypochondriasis. The extent of such disorders is not insignificant, with about 50% of people attending general medicine outpatientsestimated to have MUPS. (Muir). Low back pain, for example, has been referred to as a twentieth-century disaster, in that over the past 20 years or so there has emerged an “epidemic of chronic disability attributed to nonspecific low back pain and an increase in associated sick certification and disability and incapacity benefits, for which there is no good medical explanation and which appears to be largely a social phenomenon”.(Wadell) In more recent times, low back pain may have become ‘less sexy’ and stress and other minor psychological problems have emerged as the ‘disease’ that requires a psychosocial, as well as medical, diagnostic and treatment regimen. The existence of such phenomena has called into question the underlying models of illness. It has been argued that most models of illness assume a causal relation between disease and illness and that removal or attenuation of the disease will result in a return to health, since health is the absence of disease. It has been suggested that many of the stresses and strains witnessed in health care and illness-related benefit systems can be attributed to the emphasis on the biomedical model, and that greater emphasis should be placed on the biopsychosocial model, which assumes that disease is only one of the factors contributing to illness and illness behaviour, in order to facilitate improvement in delivery of health care and reduce incapacity to work. Therefore, in considering the level of funding required and the approaches and options available and appropriate to finance the provision of health care services, there are a wide variety of stakeholders and interest groups, whose views and perspectives need to be taken into account. In no particular order of priority they include patients and their representatives, professionals and their respective professional bodies, managers, policymakers and politicians, ethicists, the pharmaceutical industry and other providers of health equipment, insurance companies involved in health care, academic researchers and, not least, the taxpaying public. All of these groups have different goals and agendas in relation to the level of health care funding and how it is organized, and therefore it is worth prefacing the next section by emphasizing that there is no single correct system for organizing the funding of health care in a country and that there are pros and cons associated with each approach. A key policy plank of most governments would be to try and reduce the demand for health services by preventing people from getting ill in the first place. It has been estimated that preventable illness constitutes approximately 70% of the burden of illness and the associated costs48 and therefore the incentives to utilize health promotion and preventive measures for such a purpose are obviously attractive. However, there are two basic issues at stake: firstly, is there evidence that prevention and health promotion reduce health care costs; and secondly, whether any health care program or intervention should be assessed in relation to its impact on financial budgets. In response to the first it is surely the prime objective of any health care intervention or program to improve the health of the particular patients or community, which as a result may secure reductions in costs to the health service and patients and communities. The same principle should apply to any consideration of prevention and health promotion, and the more appropriate question is whether additional resources spent on prevention or health promotion would generate greater health benefits than if those resources had been used elsewhere. The second issue has grown in importance recently as purchasers have to operate within constrained budgets. The publication of guidance and guidelines, even when based on quality evidence, can have a profound impact on available resources. For example, it was argued that implementation of the guidance on statins in patients at high risk of coronary heart disease could potentially cost a single HA in the UK roughly 20% of its annual drug budget.( While health economic evaluation can be utilized in decisions relating to the prioritization of services, it is not sufficient to predict whether they are affordable within available budgets. It is becoming usual for budget impact assessment to be included alongside economic evaluations when evidence is submitted to agencies deciding on formulary inclusion or reimbursement. The plethora of different forms of health care systems around the world, with their different forms of financing and organizing the delivery of health care services, seems to imply that there is no single, unique or right way of doing things. It could also mean that different systems have evolved to suit different societies with different cultures, ideas and notions of medicine, the citizen’s right to care and so on. Reference: 1. Freemantle N, Barbour R, Johnson R et al. The use of statins: a case of misleading priorities. BMJ 1997; 315: 826–28. 2. Muir Gray JA. Evidence-based healthcare. Edinburgh: Churchill Livingstone, 1997. 3. Wanless D. Securing good health for the whole population. London: HM Treasury, 2004. http://www.hm-treasury.gov.uk./media/E43/27/Wanless04_summary.pdf (accessed December 5, 2008) 4. Waddell G, Aylward M, Sawney P. Back pain, incapacity for work and social security benefits: an international literature review and analysis. London: Royal Society of Medicine Press, 2002. 5. Wade DT, Halligan PW. Do biodmedical models of illness make for good healthcare systems? BMJ 2004; 329: 1398–401. Read More